A WATCHDOG REPORT ON TROUBLED NURSING HOMES
Last of two parts
Checking a nursing home's background is crucial in determining if Mom or Grandpa will receive good care. Has the home been in trouble before? Are there enough nurses? Are residents safe?
Yet it is easier for a consumer to find the repair and ownership history of a used car.
Mary Rismeyer knows this all too well.
Her 78-year-old mother, Dorothy Herlitz, fractured her ankle, ended up in a soft cast and needed short-term rehabilitation.
So when doctors discharged Herlitz from a Madison-area hospital in July 2006, Rismeyer needed a place that could care for her mother.
A hospital social worker suggested Willows Nursing and Rehabilitation in Sun Prairie, and Rismeyer went online to Nursing Home Compare, a Web site maintained by the federal government.
"It didn't sound too bad to me," said Rismeyer, after looking at the Web site.
What Rismeyer didn't know then was that a resident had died 14 hours after admission to Willows the prior year. The home was cited for failing to follow medical instructions in the earlier case. Inspectors typically do not determine if a nursing home's lapses directly cause a death. But the home was cited for placing patients in immediate jeopardy, records show.
No details about the death appeared on the government Web site.
More than 3 million consumers each year use the site as a guide to the quality of nursing facilities across the country. But the Journal Sentinel found that the site maintained by the Centers for Medicare & Medicaid Services offers scant detail about quality and safety.
Consumers such as Rismeyer often find themselves up against a tight deadline to find a quality nursing home.
Rismeyer's mother was admitted to Willows on July 17, 2006. A week later, she was rushed to the emergency room with an infected pressure ulcer on her fractured ankle. What medical personnel saw as they removed the soft cast from her ankle brought tears to the eyes of one physician, her daughter said.
Records show that nurses at the home had called a doctor four days earlier when they became concerned about a dark area under Herlitz's cast, but they didn't follow up when the doctor did not call back.
There was no evidence that the home monitored or implemented new procedures to stop the pressure ulcer from getting worse, the records state. By the time Herlitz was sent to the hospital, the ulcer was "dark purple and fluid filled," inspectors wrote. The home was cited for failing to promptly notify the doctor of her worsening condition.
"Her leg exploded with pus and slime and blood and stench," said Rismeyer, who was holding her mother's hand at the time.
Herlitz died 12 days later. Doctors told Herlitz, who had diabetes, that she would need to have her leg amputated because of problems stemming from the pressure ulcer, family members said. Instead, state records show, Herlitz said she "just wanted to die."
The cause of death was listed as complications of the ankle fracture, the family's attorney said. For the second time in 13 months, the nursing home was cited by state inspectors for an immediate jeopardy violation -- the most severe that can be issued.
Extendicare Homes Inc., a Canadian-based corporation that owns the home, declined to comment, citing patient confidentiality. The company owns 26 nursing homes in Wisconsin, and 20 of them have been cited for at least one serious care violation in the past three years.
Today, there are no details on the federal government's Web site about the Herlitz case, only a vague description of the citation that doesn't even indicate a death occurred.
"We as consumers don't know half the stuff we should. You don't know what to look for," Rismeyer said.
A Journal Sentinel analysis found that nursing homes in Wisconsin were cited for poor care after the deaths of 56 residents since 2005. But Nursing Home Compare doesn't offer any details about those deaths.
The Web site also doesn't mention anything about corporate ownership, meaning that consumers would be unable to determine that Extendicare, with its history of problem homes, owns Willows.
Bill proposed
The best way to make sure a loved one is entering a safe nursing home is to visit it, meet with staff and look at past inspection reports. But that process can take precious time that families just don't have, experts say.
"Figuring out who is accountable for poor care can be very difficult," said Alice Hedt, executive director of the National Citizens' Coalition for Nursing Home Reform. "Consumers often don't know who owns and operates a facility. Unless a facility tells them, there is no public way to find that out."
Making things even harder for consumers, hospitals often employ part-time social workers who might not be fully trained and might not be aware of which nursing homes have reputations for poor care, said Katherine Walsh, a professor of social work at Springfield College in Springfield, Mass.
In some cases, she said, families might be referred to nursing homes because they have a vacant bed, not because they provide quality care. Regardless, it is the family that makes the final decision, not the social worker, she said.
"It is just tragic," she said. "It is part of our patchwork health care system and shows the extreme crisis we are in."
Even when a violation is reported on Nursing Home Compare, the details are so vague that consumers would have little idea of what actually happened.
State inspection records obtained by the Journal Sentinel show that Heartland Health Care Washington Manor in Kenosha was cited in February 2007 for an immediate jeopardy violation after a resident died.
A female resident who had requested that attempts be made to revive her in the event of a heart attack died Feb. 10, 2007, "gasping for air," according to the state inspection report.
The 96-year-old woman had signed paperwork asking for medication instead of regular CPR if needed. Administrators there said they did not have the medication, and the staff wasn't trained properly to provide the service, records show. Washington Manor was cited for not providing appropriate emergency services.
But on Nursing Home Compare, consumers will see only this generic description of the incident: "Inspectors determined that the nursing home failed to give each resident care and services to get or keep the highest quality of life possible." They also won't see that the home paid more than $10,000 in fines for the incident.
Toledo, Ohio-based HCR ManorCare, which owns Washington Manor, declined to discuss the case, citing patient confidentiality.
In May, the home was cited again for placing residents in immediate jeopardy. This time, nurses tried to resuscitate a resident who did not want any life-saving measures taken, the inspection shows. They also failed to provide CPR to a resident who wanted to be resuscitated if he suffered a heart attack, records show.
As of this month, the recent citations were not listed on Nursing Home Compare.
For consumers, knowing who owns a home is important if they want to determine whether the same problems are showing up in multiple homes owned by the parent corporation.
Hedt, director of the nursing home reform organization, said her group strongly supports a bill pending in Congress that would require corporations to disclose the owners, operators and financers of nursing homes and to have that information posted on Nursing Home Compare.
The bill, called the Nursing Home Transparency and Improvement Act, also would require nursing homes to provide up-to-date information on staffing levels to the federal government. The bill is co-sponsored by Sen. Herb Kohl (D-Wis.). Now, staffing information posted on the federal Web site is "typically inflated and self-reported," Hedt said.
The number of nurses and aides on staff to help residents is a key factor in determining whether quality care is being provided, according to experts.
"The higher the staffing, the better the quality," said Charlene Harrington, a professor of sociology and nursing at the University of California in San Francisco.
Staffing numbers provided by Nursing Home Compare are merely a two-week snapshot from the most recent inspection -- and in an industry that has widespread staff turnover, those numbers can't always be trusted, Hedt said.
To get a better sense of staffing levels on a yearly basis, a consumer would have to pay hundreds of dollars for Medicaid Cost Reports from the state and spend hours analyzing a database as the Journal Sentinel did. Even then, the most recent annual data available is more than a year old.
Focusing on chains
Health and fire safety inspections on Nursing Home Compare date back to January 2005. But there isn't any information on staffing and quality measures beyond the last inspection, so families cannot see if the nursing home historically had a pattern of problems.
Mary Kahn, spokeswoman for the Centers for Medicaid & Medicare Services national office, acknowledged some of Nursing Home Compare's shortcomings but said the site is a valuable resource.
"We are not saying it's the greatest thing since sliced bread," Kahn said. "But it arms people with the information they need to take to the nursing homes in their area. The burden is on the family to go visit a nursing home, see it, smell it and meet with the administrator."
Sometimes what consumers see on Nursing Home Compare isn't even accurate.
Bonnie Zabel, administrator of Marquardt Memorial Manor in Watertown, which has not been cited for any serious deficiencies, said it took her months this year to get an incorrect citation removed from the federal Web site.
"The information is inadequate and does not tell consumers what they need to know," Zabel said.
By some measures, Nursing Home Compare has improved since its creation in 1998. Consumers visiting the Web site today would find that Willows nursing home, where Dorothy Herlitz developed her pressure ulcer, is listed as a special focus facility. The designation means it is considered one of the worst nursing homes in the country because of low quality care. Nursing Home Compare, which notes that Willows has made improvements, added the feature this year.
Also, the federal government announced in June that by the end of the year, Nursing Home Compare will unveil a "Five Star" rating system to help consumers make more informed decisions. The ratings will provide a composite view of the quality and safety on each nursing home.
However, a consumer would still not be able to tell that Willows is owned by nursing home chain Extendicare or how the company's nursing homes were performing on average nationally. While state records show that 20 of Extendicare's 26 Wisconsin homes have been cited for serious violations over the past three years, you would never know that by looking at the federal Web site.
All About Life Rehabilitation Center in Fond du Lac illustrates the problem.
In March 2007, the nursing home was cited for failing to have sufficient staff for dozens of residents who needed help eating, bathing and going to the bathroom. Five months later, the home was cited for harming a resident by failing to provide appropriate care for her pressure ulcers. And in May 2008, the home was cited for immediate jeopardy after a resident's death the month before, though inspectors did not conclude that care at the nursing home caused the woman's death.
A consumer who uses Nursing Home Compare would have no way of knowing that this home is owned by Extendicare, the same corporation that owns Willows.
The consumer transparency bill would require the federal government to develop a way to monitor nursing home chains and analyze their overall performance, Hedt said.
State has own site
Wisconsin consumers have another option that fills in some of the gaps. But the Web site, maintained by the state Department of Health Services, has its own shortcomings.
The state site posts consumer information reports that provide more in-depth data about a nursing home's turnover rates and the number of federal violations for each inspection compared with the state and county averages. But the most recentconsumer information reports available on the state's site are from the end of 2007.
State and federal nursing home inspection reports can run hundreds of pages and provide heart-wrenching detail about the violations found in a nursing home. By law, nursing homes must make the most recent inspection reports available upon request. They can also be obtained from the state Division of Quality Assurance in Madison.
But those detailed inspection reports are not posted on the state agency's Web site, something under consideration by regulators in Wisconsin. Some industry officials are against posting the inspection reports online.
John Sauer, president of the association that represents not-for-profit nursing homes in the state, said the inspection reports do not fully describe a case. Posting them online before the appeal process is completed is unfair to the provider, he said.
"There are many incidents in which the surveyors and the facility's medical staff are in complete disagreement over the facts on the treatment and implementation of the care plan," Sauer said.
Tom Moore, director of the association that represents for-profit nursing homes in the state, said inspection reports tell only one side of the story.
"I don't know what productive purpose that would serve," Moore said. "The survey process is not a good barometer of quality." To see more of the Milwaukee Journal Sentinel, or to subscribe to the newspaper, go to http://www.jsonline.com. Copyright (c) 2008, Milwaukee Journal Sentinel Distributed by McClatchy-Tribune Information Services. For reprints, email tmsreprints@permissionsgroup.com, call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.
Copyright (C) 2008 Milwaukee Journal Sentinel